PAGE 1 OF 1 PAGES FEDERAL EMERGENCY MANAGEMENT AGENCY PRELIMINARY DAMAGE ASSESSMENT SUMMARY PART 1 - APPLICANT INFORMATION NAME OF APPLICANT NAME OF LOCAL CONTACT MAINTENANCE BUDGET Approved DATE
COUNTY
PHONE NO. Date FY Begins Balance
POPULATION TOTAL BUDGET Approved CATE- NO. OF GORY SITES A B C D E F G
Balance
PART II - COST ESTIMATE - SUMMARY (COMPLETE SITE ESTIMATE BEFORE SUMMARIZING BELOW) Potential Local Funds for Recovery TYPES OF DAMAGE COST ESTIMATE FUND/ACCOUNT Available Balance Debris Removal Emergency Protective Measures Roads & Bridges Water Control Facilities Public Buildings Public Utilities Recreational or Other TOTAL 0 PART III - DISASTER IMPACTS (USE SEPARATE SHEETS IF NECESSARY) TOTAL 0
A. GENERAL IMPACT 1. Identify and describe damages which constitute a health and/or safety hazard to the general public.
2. Population adversely affected directly or indirectly by the loss of public facilities or damages.
3. What economic activities are adversely affected by the loss of public facilities or damage?
B. RESPONSE CAPABILITY: Can the applicant respond and recover from the damages quickly and without degradation of public services? Describe.
C. IMPACT ON PUBLIC SERVICES IF DECLARATION IS NOT MADE: ongoing services and capital improvements, etc. Describe.
e.g. Deferral of permanent repairs, impact on
NAME OF INSPECTOR
FEMA Form 90-80, JAN 84
AGENCY
PHONE NO.
PDA SUMMARY OF DAMAGES FOR POTENTIAL SUBGRANTEE
Public Entity/Potential Subgrantee Information Public Entity/Potential Subgrantee Total Operating Budget Population Contact and Telephone Number Maintenance Budget Additional Contacts and Telephone Numbers County Team Leader/Date of PDA
Site Estimated Summary Category Critical Facilities and Inspected Other Damages # of Sites Cost Emergency Work A. Debris B. Emer. Pro. Meas. Emergency Work sub-total 0 Permanent Work Roads & Bridges
Projected # of Sites Cost
Total # of Sites Cost
0
0
0
0
0
C.
Sub-total
0
0
0
0
0
0
D.
Water Control & Facilities Sub-total 0 0 0 0 0 0
E.
Building & Equipment Sub-total 0 0 0 0 0 0
F.
Utilities
Sub-total
0
0
0
0
0
0
G.
Parks & Other Sub-total Permanent Work Sub-total Emergency and Permanent Work Total 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0